(P76) What Lies Beneath: A Case of Traumatic Rhabdomyolysis

Chief Complaint : leg pain

History of Present Illness : 53-year-old male with no past medical history presenting with right posterior thigh pain since yesterday. He states he tripped while carrying bricks at work and fell backwards, hitting his right posterior thigh on the flat edge of a lead pipe. He reports he was able to stand up and continue working. Afterward, he went to a pharmacy and bought over-the-counter analgesics and muscle relaxers. He has been able to ambulate since but does endorse severe pain (10/10) to his posterior thigh. He denies numbness, tingling, weakness, or anticoagulant use.

Pertinent Physical Exam: ED vital signs: BP 117/71, HR 67, T 97.9 F, RR 16, SpO2 98%

On exam, the patient was calm and cooperative. He had full passive and active R hip and knee extension and flexion. There was tenderness to palpation of a mildly swollen but not tense posterior right thigh without bony tenderness. There were no ecchymoses, lacerations, or abrasions. Dorsalis pedis and posterior tibialis pulses were 2+ bilaterally. He was able to walk without assistance with a slightly antalgic gait.

Pertinent Laboratory Data: Labs: WBC 6.5, CK 11,363; ALT 133, AST 312
Normal femur x-rays.

Case Discussion: The initial differential for this patient included muscular contusion, occult fracture, compartment syndrome, rhabdomyolysis, muscular infarct, rheumatologic disease, and abscess. A muscular or osteopathic seemed most likely, given that the patient had soft compartments, no joint involvement, or infectious symptoms. Initially, the patient appeared to have a muscular contusion so he was given intramuscular toradol with a plan for reassessment. On re-examination, the patient was screaming, with pain out of proportion, for which he was given oxycodone/acetaminophen. The right posterior thigh remained slightly swollen but not tense, he was still able to actively fully flex and extend his lower extremities, there continued to be no overlying skin changes or changes in sensation, and bilateral pulses were still intact. Though these are often delayed findings, the classic “Five Ps” of compartment syndrome – pain, pulselessness, paresthesia, paralysis, and pallor – were all absent, save pain. Labs were significant for CK 11,363 (significantly greater than five times the upper limit of normal) and mild transaminitis, indicative of traumatic rhabdomyolysis. Right lower extremity x-ray imaging showed no fracture, dislocation, or bony mass. He was subsequently seen by orthopedics and deemed not to have compartment syndrome. The patient was admitted for intravenous fluids and pain control and was discharged home on day three.

References and Acknowledgements (Optional): Cabral BM, Edding SN, Portocarrero JP, Lerma EV. Rhabdomyolysis. Disease-a-Month,
Volume 66, Issue 8, 2020, 101015, ISSN 0011-5029, https://doi.org/10.1016/j.disamonth.2020.101015.

Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med 2007; 18:90.

Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. 2023 Jan 16. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 28846257.